nursing care plan for venous stasis ulcer nursing care plan for venous stasis ulcer

These measures facilitate venous return and help reduce edema. One of the nursing diagnoses in the care plan is altered peripheral tissue perfusion related to compromised circulation. Compression therapy is beneficial for venous ulcer treatment and is the standard of care. Patient information: See related handout on venous ulcers, written by the authors of this article. There are numerous online resources for lay education. Further evaluation with biopsy or referral to a subspecialist is warranted for venous ulcers if healing stalls or the ulcer has an atypical appearance. Early endovenous ablation to correct superficial venous reflux improves ulcer healing rates. Some of our partners may process your data as a part of their legitimate business interest without asking for consent. However, the dermatologic and vascular problems that lead to the development of venous stasis ulcers are brought on by chronic venous hypertension that results when retrograde flow, obstruction, or both exist. Venous Stasis Ulcer Nursing Care Plans Diagnosis and Interventions Venous stasis ulcers are late signs of venous hypertension and chronic venous insufficiency (CVI). Interventions for Venous Insufficiency Encourage the patient to elevate the legs above the level of the heart several times per day. To compile a patients baseline set of observations. Isolating the wound from the perineal region can occasionally be challenging. However, a recent Cochrane review of 22 RCTs of systemic and topical antibiotics and antiseptics for venous ulcer treatment found no evidence that routine use of oral antibiotics improves healing rates.1 Studies comparing topical antibiotics and antiseptics, such as povidone-iodine solution (Betadine), peroxide-based preparations, ethacridine lactate (not available in the United States), and mupirocin (Bactroban), have found some evidence to support the use of the topical antiseptic agent cadexomer iodine (not available in the United States; a pooled estimate from two trials suggests an increased healing rate at four to six weeks compared with placebo).1 More high-quality data are needed to better evaluate the effectiveness of topical preparations, however.1. Because of limited evidence and no long-term benefit, hyperbaric oxygen therapy is not recommended for treatment of venous ulcers.47, Negative Pressure Wound Therapy. St. Louis, MO: Elsevier. Stockings or bandages can be used; however, elastic wraps (e.g., Ace wraps) are not recommended because they do not provide enough pressure.45 Compression stockings are graded, with the greatest pressure at the ankle and gradually decreasing pressure toward the knee and thigh (pressure should be at least 20 to 30 mm Hg, and preferably 30 to 44 mm Hg). Start providing wound care according to the decubitus ulcers development. Calf muscle contraction and intraluminal valves increase prograde flow while preventing blood reflux under normal circumstances. A simple non-sticky dressing will be used to dress your ulcer. Inelastic compression wraps, most commonly zinc oxideimpregnated Unna boots, provide high compression only during ambulation and muscle contraction. Compression therapy reduces edema, improves venous reflux, enhances healing of ulcers, and reduces pain.23 Success rates range from 30 to 60 percent at 24 weeks, and 70 to 85 percent after one year.22 After an ulcer has healed, lifelong maintenance of compression therapy may reduce the risk of recurrence.12,24,25 However, adherence to the therapy may be limited by pain; drainage; application difficulty; and physical limitations, including obesity and contact dermatitis.19 Contraindications to compression therapy include clinically significant arterial disease and uncompensated heart failure. Poor venous return is due to damage of the valves in leg veins that facilitate the return of the blood to the heart. Most patients have venous leg ulcer due to chronic venous insufficiency. Venous Ulcers. The primary risk factors for venous ulcer development are older age, obesity, previous leg injuries, deep venous thrombosis, and phlebitis. Enzymatic debridement using collagenase has been shown to effectively remove nonviable tissue. Conclusion Poor prognostic factors include large ulcer size and prolonged duration. All Rights Reserved. Pressure Ulcer Nursing Care Plans Diagnosis and Interventions Pressure Ulcer NCLEX Review and Nursing Care Plans Pressure ulcers, sometimes called bedsores or Decubitus ulcers, are skin and tissue breakdown that arises from exertion of incessant pressure to the skin. Risk Factors Trauma Thrombosis Inflammation Embolism Goals and Outcomes On physical examination, venous ulcers are generally irregular and shallow with well-defined borders and are often located over bony prominences. Although the main goal of treatment is ulcer healing, secondary goals include reduction of edema and prevention of recurrence. Otherwise, scroll down to view this completed care plan. c. There are many cellular and tissue-based products approved for the treatment of refractory venous ulcers, including allografts, animal-derived extracellular matrix products, human-derived cellular products, and human amniotic membranederived products. List of orders: 1.Enalapril 10 mg 1 tab daily 2.Furosemide 40 mg 1 tab daily in the morning 3.K-lor 20 meq 1 tab daily in the morning 4.TED hose on in AM and off in PM 5.Regular diet, NAS 6.Refer to Wound care Services 7.I & O every shift 8.Vital signs every shift 9.Refer to Social Services for safe discharge planning QUESTIONS BELOW ARE NOT FOR The first step is to remove any debris or dead tissue from the ulcer, wash and dry it, and apply an appropriate dressing. This hemorheologic agent affects microcirculation and oxygenation, and can be used effectively as monotherapy or with compression therapy for venous ulcers.1,39 In seven randomized controlled trials, pentoxifylline plus compression improved healing of venous ulcers compared with placebo plus compression. This process is thought to be the primary underlying mechanism for ulcer formation.10 Valve dysfunction, outflow obstruction, arteriovenous malformation, and calf muscle pump failure contribute to the pathogenesis of venous hypertension.8 Factors associated with venous incompetence are age, sex, family history of varicose veins, obesity, phlebitis, previous leg injury, and prolonged standing or sitting posture.11 Venous ulcers result from a complex process secondary to increased pressure (venous hypertension) and inflammation within the venous circulation, vein wall, and valve leaflet with extravasation of inflammatory cells and molecules into the interstitium.12, Clinical history, presentation, and physical examination findings help differentiate venous ulcers from other lower extremity ulcers (Table 15 ). In diabetic patients, distal symmetric neuropathy and peripheral . C) Irrigate the wound with hydrogen peroxide once daily. Choice of knee-high, thigh-high, toes-in, or toes-out compression stockings depends on patient preference. Patient information: See related handout on venous ulcers. The patient will employ behaviors that will enhance tissue perfusion. Current evidence supports treatment of venous ulcers with compression therapy, exercise, dressings, pentoxifylline, and tissue products. Duplex Ultrasound The search included meta-analyses, randomized controlled trials, clinical trials, and reviews. . Venous incompetence and associated venous hypertension are thought to be the primary mechanisms for ulcer formation. Despite a number of studies to support its effectiveness as adjunctive therapy, and possibly as monotherapy, the cost-effectiveness of pentoxifylline has not been established. Debridement may be sharp (e.g., using curette or scissors), enzymatic, mechanical, biologic (i.e., using larvae), or autolytic. Compression therapy. Remind the client not to cross their legs or hyperextend their knees in positions where they are seated with their legs hanging or lying jackknife. Although intermittent pneumatic compression is more effective than no compression, its effectiveness compared with other forms of compression is unclear. Provide information about local wound care to the patient and the caregiver, and then let them watch a demonstration. Venous stasis commonly presents as a dull ache or pain in the lower extremities, swelling that subsides with elevation, eczematous changes of the surrounding skin, and varicose veins.2 Venous ulcers often occur over bony prominences, particularly the gaiter area (over the medial malleolus). Author disclosure: No relevant financial affiliations. The patient verbalized 2 exercise regimens to improve venous return to help promote wound healing within 12-hour shift by elevated her legs and had antiembolism stockings on all day, continue to reevaluate or educate patient. Impaired Skin Integrity ADVERTISEMENTS Impaired Skin Integrity Nursing Diagnosis Impaired Skin Integrity May be related to Chronic disease state. Tiny valves in the veins can fail. Contraindications to compression therapy include significant arterial insufficiency and uncompensated congestive heart failure.29, Elastic. Skin grafting should be considered as primary therapy only for large venous ulcers (larger than 25 cm2 [3.9 in2]), in which healing is unlikely without grafting. Her Waterlow Scale is 16, and her skin is intact except for the venous stasis ulcer on the right medial malleolus. You will undertake clinical handover and complete a nursing care plan. Compression therapy is a standard treatment modality for initial and long-term treatment of venous ulcers in patients without concomitant arterial disease. This usually needs to be changed 1 to 3 times a week. Leg elevation minimizes edema in patients with venous insufficiency and is recommended as adjunctive therapy for venous ulcers. The Unna boot improves healing rates compared with placebo or hydroactive dressings.22,26 However, a 2009 Cochrane review found that adding a component of elastic compression therapy is more effective than inelastic compression therapy alone.45 Also, because of its inelasticity, the Unna boot does not conform to changes in leg size and may be uncomfortable to wear. Stasis ulcers. In a small study, patients receiving simvastatin (Zocor), 40 mg once daily, had a higher rate of ulcer healing than matched patients given placebo.42, Phlebotonics. Venous ulcers are open skin lesions that occur in an area affected by venous hypertension.1 The prevalence of venous ulcers in the United States ranges from 1% to 3%.2,3 In the United States, 10% to 35% of adults have chronic venous insufficiency, and 4% of adults 65 years or older have venous ulcers.4 Risk factors for venous ulcers include age 55 years or older, family history of chronic venous insufficiency, higher body mass index, history of pulmonary embolism or superficial/deep venous thrombosis, lower extremity skeletal or joint disease, higher number of pregnancies, parental history of ankle ulcers, physical inactivity, history of ulcers, severe lipodermatosclerosis (panniculitis that leads to skin induration or hardening, increased pigmentation, swelling, and redness), and venous reflux in deep veins.5 Poor prognostic signs for healing include ulcer duration longer than three months, ulcer length of 10 cm (3.9 in) or more, presence of lower limb arterial disease, advanced age, and elevated body mass index.6, Complications of venous ulcers include infections and skin cancers such as squamous cell carcinoma.7,8 Venous ulcers are a major cause of morbidity and can lead to high medical costs.3 Economic and personal impacts include frequent visits to health care facilities, loss of productivity, increased disability, discomfort, need for dressing changes, and recurrent hospitalizations. History of superficial or deep venous thrombosis, pulmonary embolism, and ulcer recurrence should be ascertained with comorbid conditions. Elastic bandages (e.g., Profore) are alternatives to compression stockings. Pentoxifylline (400 mg three times per day) has been shown to be an effective adjunctive treatment for venous ulcers when added to compression therapy.31,40 Pentoxifylline may also be useful as monotherapy in patients who are unable to tolerate compression bandaging.31 The most common adverse effects are gastrointestinal (e.g., nausea, vomiting, diarrhea, heartburn, loss of appetite). As an Amazon Associate I earn from qualifying purchases. Buy on Amazon. Examine the clients and the caregivers comprehension of pressure ulcer development prevention. Preamble. Venous ulcers, also known as venous stasis ulcers are open sores in the skin that occur where the valves in the veins don't work properly and there is ongoing high pressure in the veins. This article reviews the incidence and pathophysiology of CVI, nursing assessment, diagnosis and interventions, and patient education needed to manage the disease and prevent . This causes blood to collect and pool in the vein, leading to swelling in the lower leg. They typically occur around the medial malleolus, tend to be shallow and moist, and may be malodorous (especially when poorly cared for) or painful. Elderly people are more frequently affected. Compression therapy is a standard treatment modality for initial and long-term treatment of venous ulcers in patients without concomitant arterial disease. Date of admission: 11/07/ Current orders: . Ulcers are open skin sores. A group of nurse judges experienced in the treatment of venous ulcer validated 84 nursing diagnoses and outcomes, and 306 interventions. Chronic venous insufficiency can develop from common conditions such as varicose veins. Evidence has not shown that any one dressing is superior when used with appropriate compression therapy. Nursing care planning and management for ineffective tissue perfusion is directed at removing vasoconstricting factors, improving peripheral blood flow, reducing metabolic demands on the body, patient's participation, and understanding the disease process and its treatment, and preventing complications. Unna boots have limited capacity for fluid absorption in patients with highly exudative ulcers and are best used for early, small, dry ulcers and for venous dermatitis because of the skin soothing effects of zinc oxide.30, Stockings. Nursing Interventions 1. Venous stasis ulcers may develop spontaneously or after affected skin is scratched or injured. Anna Curran. The ultimate aim is to promote evidence-based nursing care among patients with venous leg ulcer. Venous thromboembolism occurs majorly in two ways like pulmonary embolism and deep vein thrombosis. Hyperbaric oxygen therapy has also been proposed as an adjunctive therapy for chronic wound healing because of potential anti-inflammatory and antibacterial effects, and its benefits in healing diabetic foot ulcers. Physically restricting circulation reduces blood flow and heightens venous stasis in the pelvic, popliteal, and leg veins, causing swelling and discomfort to worsen. Position the patient back in his or her comfortable or desired posture. Venous ulcers (also known as venous stasis ulcers or nonhealing wounds) are open wounds around the ankle or lower leg. Between 75 % and 80 % of all lower limb ulcers is of venous etiology, their prevalence ranges between 0.5 % and 2.7 %, and increase with age (2, 3). Care Plan Provider: Jessie Nguyen Date: 10/05/2020 Inelastic. Teach the caretaker how to properly care for the afflicted regions of the wounds if the patient is to be discharged. document.getElementById("ak_js_1").setAttribute("value",(new Date()).getTime()); This site uses Akismet to reduce spam. Venous Leg Ulcers are the most common type of lower extremity wound, afflicting approximately 1% of the western population during their lifetime. VLUs also represent a significant burden for patients and healthcare systems.. Learn how your comment data is processed. Any of the lower leg veins can be affected. Venous stasis ulcers are late signs of venous hypertension and chronic venous insufficiency (CVI). Venous stasis ulcers often present as shallow, irregular, well-defined ulcers with fibrinous material at the base at the distal end of the legs across the medial surface. She found a passion in the ER and has stayed in this department for 30 years. Venous ulcers, or stasis ulcers, account for 80 percent of lower extremity ulcerations.1 Less common etiologies for lower extremity ulcerations include arterial insufficiency; prolonged pressure; diabetic neuropathy; and systemic illness such as rheumatoid arthritis, vasculitis, osteomyelitis, and skin malignancy.2 The overall prevalence of venous ulcers in the United States is approximately 1 percent.1 Venous ulcers are more common in women and older persons.36 The primary risk factors are older age, obesity, previous leg injuries, deep venous thrombosis, and phlebitis.7, Venous ulcers are often recurrent, and open ulcers can persist from weeks to many years.810 Severe complications include cellulitis, osteomyelitis, and malignant change.3 Although the overall prevalence is relatively low, the refractory nature of these ulcers increase the risk of morbidity and mortality, and have a significant impact on patient quality of life.11,12 The financial burden of venous ulcers is estimated to be $2 billion per year in the United States.13,14, The pathophysiology of venous ulcers is not entirely clear. Conclusion The highest CEAP severity score is applied to patients with ulcers that are active, chronic (greater than three months' duration, and especially greater than 12 months' duration), and large (larger than 6 cm in diameter).19,20 Poor prognostic factors for venous ulcers include large size and prolonged duration.21,22.